Distributor Application and Agreement Complete application or apply online at www.SeneGence.com PLEASE PRINT CLEARLY USING A DARK PEN Sponsor’s Name Sponsor’s ID Number PLEASE COMPLETE THE FOLLOWING INFORMATION: Shipping Address (NO P.O. Boxes) Full Legal Name of Applicant (Last, First, Middle Initial) Applicant Hong Kong Identity Card Number (HKID) Birthday District D D M M Daytime Telephone Number Evening Telephone Number Fax Number Mobile Phone Number Email Address My signature below indicates that I have read and accepted all the terms and conditions regarding privileges and obligations as set forth in the Terms of Application and Agreement, on the back of this agreement and that I have read and agree to be bound by the Policies and Procedures Guide. All signatures to this application must be affixed personally. Applicant must be of legal age and a resident of Hong Kong. A PARTICIPANT HAS THE RIGHT TO CANCEL AT ANY TIME, REGARDLESS OF REASON. CANCELLATION MUST BE SUBMITTED IN WRITING TO THE COMPANY AT ITS PRINCIPAL BUSINESS ADDRESS: Unit 613 6/F Mira Place Tower A, 132 Nathan Road, Tsim Sha Tsui, Kowloon, Hong Kong. email: [email protected] Tel: +852 3892 823 X Signature of Applicant Date DD / MM / YY For efficient handling of your application, please sign and return both the front and back of this document. Applications without both signatures will not be accepted by SeneGence. SeneGence reserves the right to refuse the acceptance of any Distributor Application or to rescind such acceptance within thirty (30) days, for any reason. I object to Senegence using my personal data in direct marketing as referred to in the section entitled 'Use of Personal Data in Direct Marketing* ' of the notice. * Direct Marketing can include offers of special discount, coupons or gift items..